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Month: October 2014

I am a surgeon. I am not an Epidemiologist nor an Infectious Disease specialist. Anything I say on this subject should be regarded as the musings of an educated layman. That said, I have been profoundly disappointed in the response of my profession to the current Ebola scare in this country. I don’t use the word crisis because it is not a crisis in the United States. The crisis is in West Africa. Nevertheless, the media have done little to calm fears of rampant spread of the disease to America.

The response of our professional organizations and public health institutions has been scientifically correct and yet has been an abject failure in the eyes of the public. The guidelines coming out of CDC and the Public Health Service seem fragmented, incoherent and sometimes contradictory. Measures which in the public mind seem reasonable, such as flight bans and quarantines, are dismissed with an attitude of superiority that borders on arrogance. I know the reasons that such measures were not recommended, but those reasons were not communicated in such a way that the lay person could understand and support. Instead, the response of the experts sounds dismissive and political rather than reasonable and scientific. Leadership involve more than issuing the correct orders and directives. It also means effective communication of the mission and goals of the organization. In this case, there has been a failure of leadership from the top.

Some of the irrationality about this disease can be blamed on the media, both the immediate reaction and the more general flight from science and distrust of expertise on the part of much of the general public. But in the 24hr news cycle of today, perception becomes reality. The experts in this case have done little to alter the perception that they are either political hacks or arrogant academics who are out of touch with the fears of the general public. The overly aggressive reaction of officials in New York and New Jersey appear decisive and prudent to a fearful but poorly informed lay person.

The unfortunate handling of the Ebola admission in Dallas and the subsequent exposure of two nurses to potential infection further confirmed the poor preparation of the healthcare system and the lack of effective training of frontline personnel.

Appearances by celebrity physicians in isolation garb that was improperly donned and removed and then purport to show how easy it is to become exposed do little to allay public concerns.

Statements by public health officials that we don’t need such aggressive containment and quarantine procedures as countries in the immediate area of the outbreak because ‘our healthcare systems are better’ simply sound arrogant rather than explaining the reality behind that assertion.

Then there are the actions of a pair of healthcare professionals who in my mind should have known better. If I were returning from the Ebola hot zone and had had direct contact with infected patients, no matter how thorough my precautions may have been, I would place myself in voluntary home quarantine for the duration of the incubation period. Even if I had no fever or symptoms, it would seem irresponsible to me to ride a crowded subway or engage in public social activities until there was absolutely no question that I might have the disease.

Similarly, even if I thought a public health official had overstepped the bounds of common sense in placing me in quarantine, I would not bleat about it in a public forum, or hire a lawyer to defend my ‘human rights’. Such action only makes our profession look arrogant and irresponsible; more concerned with our own rights and prerogatives than with the public good. It undermines any rational discussion of true risks and benefits and places the handling of public health in the political arena.

In truth, the risks to the public in this country are low. This outbreak will eventually be contained and burn out in West Africa. But I fear that the message to the public will be that the medical profession is out of touch with their fears, arrogant in their treatment of the problem and inept in the implementation of that treatment.

He came to my office last Tuesday, asking for more pain medication. He had a couple of drains in his right side that should have been removed two weeks earlier, but he missed that appointment. Phone calls from my office went to a generic voice mail and messages went unanswered.

On Monday he finally called the office demanding to be seen immediately. My receptionist got him in at the end of the office schedule the next day.

It started a month earlier with a drug deal gone bad. Either he tried to cheat someone or they tried to cheat him, the story was never really clear. What was clear was that someone really wanted him dead.

He was shot twice in the chest, and once through the abdomen. Whoever shot him took whatever money or drugs he had on him and left him for dead. Instead he got lucky. The clerk at a convenience store nearby heard the shots and called 911. A police unit happened to be in the area and responded within two minutes. They found the kid (he’s only 22 years old) within five minutes and the paramedics arrived only five minutes after that. Within thirty-five minutes of being shot in an alley behind a strip mall, he was in my trauma bay.

We started blood and plasma. I put tubes into both chest cavities to evacuate blood and trapped air and checked for entrance and exit wounds. We had him in the operating room within fourteen minutes of arrival.

The bullet that entered his abdomen did the most damage. It shattered the right lobe of his liver, tore through the upper part of his right kidney, and clipped the lateral wall of his vena cava before traveling through the lower edge of his stomach, ending up in the muscle of his abdominal wall.

We fixed the hole in the vena cava, repaired the upper part of the kidney and cleaned up and drained the liver injury. Twenty units of blood and plasma, two hours of surgery and he was stable in the ICU. I went off service at that point and turned him over to the ICU Trauma Surgeon.

He spent two more weeks in the hospital before being discharged. Apparently he complained the whole time about his pain not being addressed despite huge doses of narcotics and an evaluation by the Pain Management specialists.

Then he started calling my office. Usually, trauma patients follow up with the trauma clinic at the hospital for their postop care. I will often see patients that I operate on in follow up, but usually only when they have an open wound or are going to need further surgery to address an ongoing problem. My staff directed him to the trauma clinic but he had various excuses as to why he couldn’t go. Never once was it his problem. It was always someone else who let him down or gave him bad information or didn’t do their job.

We went ahead and scheduled a follow up for about ten days after his hospital discharge, that appointment that he subsequently missed.

Since then I have seen him twice and my office has fielded many more phone calls. He hasn’t followed up as instructed, he has ‘lost’ or been unable to obtain his prescription pain medications time and again and the only time he can be relied on to call is when he runs out of narcotics. Not once has he acknowledged that he nearly died and voiced any appreciation for the team that saved his life.

This is the less rewarding side of a trauma practice. Trauma is a disease of the marginalized, the addicted, the alcoholic, the disenfranchised. In my experience, only about ten percent of traumas occur to regular everyday working folks who are blind-sided by a major injury. The majority of trauma patients have chronic underlying issues that make caring for them difficult and frustrating.

I find that as I have gotten older, my ability to make allowances for their behavior and tolerate their demands has worn thin. Perhaps it’s burnout, or compassion fatigue. Maybe I’m just tired of dealing with people who can’t or won’t take responsibility for themselves. My Chief used to say that if you want to be a hero, get a dog. I don’t necessarily want kudos for doing my job, but would like to feel that I made a difference.

Occasionally I am surprised. Occasionally, a life-threatening trauma is a transformative experience, causing a patient to take stock of their life and begin to make changes. But to distressing degree, all many patients find is pain, bitterness and blame. They can’t see that their actions had anything to do with their injuries and as quickly as they can, they return to the same behaviors that got them into the trauma bay in the first place.

I have written before about my role as a craftsman, about how I see the integrity of my work in the OR as an end in itself. A good outcome for the patient is a happy consequence of that effort to do my best, but is not the primary motive for that effort. Some days, that commitment to the work itself is the only thing that keeps me from being overwhelmed by the futility of dealing with the people I serve.

I did an urgent laparoscopic cholecystectomy the other day on a young woman who called the office with a sudden worsening of her gallbladder symptoms. By the time we got her to the OR preop area, she was pale, diaphoretic (cold and sweaty) and writhing in pain. Her gallbladder was sick but not infected and she had a stone stuck tight in her cystic duct, the tube that drains the gallbladder. The stuck gallstone was probably what caused the sudden worsening of her symptoms.

I had originally seen her in the office late in July, just before I went on vacation. She was having episodes of upper abdominal pain once or twice a week and had gallstones diagnosed by ultrasound. She’s an otherwise healthy thirty year old who had stones diagnosed on a pregnancy ultrasound and symptoms that started four months after the recent birth of her third child–pretty typical history. She took no prescription medications but did take a handful of herbal and vitamin supplements daily and told me she stayed away from processed foods in favor of a ‘natural’ diet. That should have tipped me off, but it didn’t at the time.

The surgery went well, although the stone was wedged pretty tightly and I did an x-ray of the common bile duct, the main tube that drains bile from the liver, just to make sure no other rocks had gotten away from us.

When I talked to her family after surgery, her husband asked if the ‘purge’ had worked. I asked what he meant and he told me she had read about a gallbladder purge that was supposed to get rid of stones ‘naturally’ and had tried it a couple of days before. The increased pain and the stuck gallstone now made sense.

These purges are touted on various websites as a natural cure for gallstones. There are several popular ones, but they all involve a fast of several days followed by a large dose of olive oil or similar fatty meal. The idea is to make the gallbladder ‘expel’ the stones. These purges are at best a bad idea and at worst dangerous.

Why? First, a few words about the gallbladder and what it does. The gallbladder stores bile. When we eat, especially a meal rich in fat, the stomach and intestine secrete a hormone called cholecystokinin (CCK), which causes the gallbladder to contract and push a big slug of bile into the common bile duct and through it into the intestine. Bile acts like detergent to break fat into smaller globs that the digestive enzymes can work on. People have gallbladders because for most of human history, food supplies were unreliable. Especially for our hunter-gatherer ancestors. They might eat a large meal one day and then little or nothing the next. An organ to store bile during fasting and mobilize it in response to a meal prevented crippling diarrhea from poorly digested fat.

When we eat every day, which most people in this country do, and especially when the quantity and quality of our food doesn’t vary much, the gallbladder can languish. It has nothing to do. That may be why some gallbladders form stones. We don’t really know. But we do know that healthy gallbladders don’t allow stones to form in the first place. So if you have gallstones, your gallbladder isn’t working very well.

Purges try to take the normal physiology of the gallbladder and use it to pass the stones out into the bile duct and thence into the intestine. Sounds nice, but in practice, only small stones can pass this way. And, because the bile duct is a low pressure/low flow system, even then they often get stuck. A larger stone will just wedge itself into the duct and jam up there, causing unrelenting pain and setting up the potential for an infection or even a ruptured gallbladder.

I see five or six patients a year who come to my office or to the ER acutely ill after one of these purge attempts. Often they were referred to a website by a helpful friend, or worse, had the purge prescribed by one of those charlatans who call themselves ‘Naturopathic Physicians’. Just because it’s natural, doesn’t make it safe. (Hemlock is a natural substance but it wasn’t very good for Socrates.) You may know a friend or a friend of a friend of a friend’s second cousin who ‘cured’ gallstones this way, but that doesn’t make it a good idea.

On the other hand, it doesn’t hurt my business to have a patient who is convinced in such a graphic way that they need an operation. Olive oil cocktail, anyone?

Late night Saturday trauma, 59-year-old woman in a high speed head on collision. She was not restrained and ended up bend almost double, pinned under the steering wheel and dashboard of her car. Thirty-minute extraction, seventeen minute transport time. We’re now three quarters of the way through that first golden hour when rapid intervention can still make a difference.

Her vitals were all over the map in the ambulance, heart rate swinging between the low 60’s and up to 120. Her blood pressure would be normal one minute and then drop to the 50’s the next.

In the trauma bay we had the low end of that swing. We placed another large bore IV and started pouring in fluids and O negative blood. Her blood pressure briefly rose to the high 90’s. She opened her eyes and looked at me. She said, “I can’t breathe. Help me.” And then she died.

Her blood pressure went away completely, not recordable. Her heart rate, which had been 120, fell to 40 and the pattern changed from normal sinus to a junctional rhythm (the last ditch effort of a dying heart to keep going).

It’s called PEA – pulseless electrical activity. The electrical system of the heart is still firing but no contraction is taking place either because the heart is empty or because it can’t fill. I bet on the latter and call for the thoracotomy tray.

ER thoracotomy is a dramatic event. It’s also usually futile. Survival after opening someone’s chest in the ER is less than 10% under most circumstances. A few centers report better results with penetrating trauma. But almost universally the survival with ER thoracotomy for blunt trauma is zero. My personal experience in thirty years is two survivors, one penetrating and one blunt.

I opened her chest through a left lateral incision through the space between the 5th and 6th ribs and extended it across the sternum. Her pericardium, the membrane around her heart, was filled with clot and the blood was squeezing the heart so it couldn’t pump. I opened the pericardium and evacuated the clot and her heart filled and started to beat.

Yes! I thought, watching the ventricle fill and contract. Then I saw the same blood that filled her ventricle rush out of the aortic valve annulus and the darker blood pouring out of the hole in her superior vena cave. She’d avulsed her heart from the superior mediastinum – ripped it off of the major vessels in the upper chest. In about twenty seconds the heart fasciculated and stopped.

First principles – mortality for ER thoracotomy in blunt trauma is 100%. But she opened her eyes and spoke to me. Sometimes you need to make a grand futile gesture, just so you can sleep at night

Cicero once said, “Treat not with men who have no honor. You are both dishonored in the exchange but they have nothing to lose.”

What then is the proper course of action when confronted with a powerful organization that one believes is behaving unethically? The easy answer, the one that most people will give automatically (and somewhat self-righteously), is to refuse to do business with that organization.

But what if the organization is behaving in a perfectly legal and businesslike manner? What if, nevertheless, that behavior violates you own code of ethics, and arguably the larger ethical standard of ‘what is right and just’?

I find myself wrestling with that question right now. Many of my peers think I’m overstating the problem or that I’m being too idealistic. Many agree that the organization may not be a paragon of virtue, but they are scrupulously obeying the letter of the law, so there are no grounds for complaint.

The large hospital system that operates the hospital where I do most of my elective surgery (not the trauma center where I also work) has instituted a policy of requiring payment in full of that portion of the total bill for which the patient is responsible BEFORE any non-emergent surgery can be scheduled. In other words, if you have one of the 80/20 insurance plans sold under the ACA exchange, or if your employer provided plan has such a payment scheme, the hospital wants your 20% up front. They won’t waive it or let you finance it other than on a major credit card. The only exceptions are ‘emergencies’.

So far so good. I am a big proponent of individual responsibility. Patients are responsible for the deductibles on their insurance plan, and a prudent person puts money aside for that. I don’t have a big problem with such a policy for purely elective surgery such as the asymptomatic hernia or the elective hysterectomy or gallbladder surgery. But the hospital is taking a hard line on what constitutes and emergency. Specifically, an emergency is a life or limb threatening problem or one that will cause the patient irreparable harm if not treated immediately. The key word is immediately, as in today, not tomorrow or next week.

Recently I received word from yet another patient that she was unable to go ahead with surgery due to the policy of demanding payment in advance of her copayment of 20% of her anticipated hospital bill. I was asked if her surgery was an emergency. Usually for scheduled cases I do not certify them as emergent, but in this case I answered that it was. The patient had originally been scheduled for a laparoscopic cholecystectomy in a month, but came to my office urgently with crescendo symptoms. Her right upper quadrant pain had become much worse and was now almost continuous and required narcotics for control. I moved her surgery up to the next available day, 48 hours after seeing her in my office. She went straight to the registration area to set up her surgery and was told she would have to pay a large sum in advance based on her insurance plan. She did not have the money or the available credit on a credit card to pay. After I said it was an emergency, she was referred to hospitals Chief Medical Officer who reviewed her case and apparently her finances and somehow decided that it was appropriate for her to pay $500. Again, she stated she did not have that much cash and so she cancelled her surgery. I eventually did her surgery at the trauma center where I work and where there is no review of a surgeon’s decision that a surgery is urgent or emergent.

This is not the first time this has occurred. I and several other surgeons have had patients in need of cancer surgery have the same issue with respect to demands for advance payment of large sums prior to scheduling surgery. I have discussed this personally with the CMO and also with the Medical Staff President. While I understand the issue of bad debt resulting from patients failing to pay their share of their medical bills, I have little sympathy for the system’s pleas of financial hardship as a result of it. On any given day, thirty percent of my billing is bad debt. As a solo private practitioner, my ability to tolerate and finance that debt is surely more limited than a large organization such as the one that owns and operates my primary hospital. If this bad debt is so crippling, then how is this same hospital system able to buy hospitals all over the state and take over management of the state medical school?

I object strongly to having my clinical judgment as a surgeon over ruled by the hospital CMO, especially when he is neither a surgeon nor in the active day-to-day practice of patient care. I further think it is inappropriate for him to be making financial judgments with respect to a patient’s ability to pay. It is one thing to ask for advance payment for a purely elective surgery such as the repair of an asymptomatic hernia. It is both medically and morally indefensible to place financial considerations ahead of care in cases of cancer surgery or where a surgeon has declared that the surgery is urgent or emergent. To limit waiver of the advance payment to life threatening emergencies only may satisfy any legal responsibility, but such a policy compromises patient care in situation such as my patient’s. She did not have a life-threatening problem but was unable to function normally until her surgical disease was addressed. This policy needs to be changed. I know the satisfaction of a single patient means little to the hospital, but this particular patient has refused to have anything to do with the hospital, now or in the future. As more and more people experience similar treatment, patient satisfaction is sure to suffer.

I suggest that first, the CMO actually discuss the clinical situation with the patient’s surgeon if he chooses to over rule the declaration of an emergency. Second, a third category of ‘urgent but not emergent’ needs to be created for patients such as mine – people who are not in imminent danger of death or complication but who still need surgery as soon as practically possible. Third, the CMO should be removed from any financial decision making about how much it is appropriate for a patient to pay if that is to be less than full payment. There are financial professionals who do that job all the time in the business world. The hospital needs to hire appropriate people to look at this issue the same way that a debt counseling service would. The current situation is unconscionable for an organization that professes to make a positive difference in people’s lives.

While the policy is unquestionably legal, adhering to the strict letter of the law, it is not, in my opinion, ethical. It does not support justice or do what is best for the patients who seek care at this institution.

So what does a lone surgeon do? I have written multiple letters of protest, brought the subject up at departmental meetings, and had conversations with the CMO and the CEO of the hospital, all of which have proven futile. Do I continue to bring my patients here and thereby tacitly support this policy? Do I resign from the staff? That would hurt no one but me. In fact, I’m sure the CEO and a number of administrators would be glad to have me out of their hair. Resigning would also inconvenience my patients, most of whom live near my office. There is no alternative hospital that isn’t owned by the same system within 15 miles.

For now, I will continue to protest this policy at every opportunity. But am I just being naïve? Is this the way of the future? The ACA has made the high deductible, 80/20 plans the industry standard. There will be more pressure on hospitals and patients both. But through all the argument over personal responsibility, bad debt, and the definitions of medical necessity and emergency care, we need to maintain or commitment to doing what is best for our patients. We need to continue to do right and seek justice.